Center for Humans and Nature, 109 West 77th Street, Suite 2, New York, NY 10024, USA. Tel.: 212 362 7170; Fax: 212 362 9592; Email: brucejennings{at}humansandnature.org ' + u + '@' + d + ' '//--> . Abstract A fundamental question for the ethical foundations of public health concerns the moral justification for limiting or overriding individual liberty. What might justify overriding the individual moral claim to non-interference or to self-realization? This paper argues that the libertarian justification for limiting individual (...) liberty known as the ‘harm principle’ or the ‘Millian paradigm’ is inadequate as a basis of public health ethics and policy. But simply pitting some collectivist value or utilitarian criterion over against individual liberty is not theoretically satisfactory, either. John Stuart Mill himself was not a Millian, in this sense, and his utilitarianism does not pit itself against individual liberty as a situation of balancing conflicting values. A reconsideration of Mill, particularly in light of the later work of Berlin on liberty, points toward a conception of relational liberty that is crucial for public health ethics because it contains within itself the basis for its own moral limitation. CiteULike Connotea Del.icio.us What's this? (shrink)

Public health involves the use of power to change institutions and redistribute resources and deliberately to shape individual thought and behavior. This requires normative legitimation and demands ethical critique. This article explores concepts that are vital to public health ethics, but have been relatively neglected. These are membership, solidarity and the concept of place. The article argues that the practice of public health should recognize the equal rights of membership in communities of health justice. Public health should also rely on (...) a sense of obligation and mutual aid in a world of shared vulnerability and reciprocal recognition. Finally, public health achieves its goals not merely—and perhaps not most fundamentally—through information and altering the logical ratiocination of individuals or groups, but rather through the reformation of sense and sensibility. (shrink)

How important is the concept of solidarity in our society's calculus of consent as regards the legitimacy and ethical and political support for public health, health policy, and health services? By the term “calculus of consent,” we refer to the answer that people give to rationalize and justify their obedience to laws, rules, and policies that benefit others. The calculus of consent answers questions such as, Why should I care? Why should I help? Why should I contribute to the public (...) provision of others? Consent here does not have to be a deliberate, explicit act of informed agreement. And a calculus does not have to be a quantifiable, quasimathematical operation; more often, such a calculus takes narrative form in stories that a society tells about itself and that individuals tell about their place in it. One vital function of bioethics is to inform and shape those stories. Bioethics has the potential to offer society a keener insight into and perception of what is ethically at stake in controversies concerning health, science, and society. This insight is what we shall refer to as a “moral imagination,” by which we do not mean make-believe or fantasy but, rather, the capacity to take a critical distance from the given, to think reality otherwise. The moral imagination enables one to see connections between factors at work in history, in large social and communal structures, and in the shape of one's own life, thoughts, and feelings. Here we are especially concerned with the contribution that the concept of solidarity can make to the moral imagination of bioethics. We contend that solidarity must become more widely active and explicit in bioethics analysis and argumentation as it endeavors to shape reasons for obeying norms and rules of common benefit in an open, diverse society. (shrink)

Discussions of research involving vulnerable populations have left the homeless comparatively ignored. Participation by these subjects in drug studies has the potential to be upsetting, inconvenient, or unpleasant. Participation occasionally produces injury, health emergencies, and chronic health problems. Nonetheless, no ethical justification exists for the categorical exclusion of homeless persons from research. The appropriate framework for informed consent for these subjects of pharmaceutical research is not a single event of oral or written consent, but a multi-staged arrangement of disclosure, dialogue, (...) and permission-giving. Payments and other rewards in biomedical research raise issues of whether it is ethical to offer inducements to the homeless in exchange for participation in drug studies. Such inducements can influence desperate persons who are seriously lacking in resources. The key is to strike a balance between a rate of payment high enough that it does not exploit subjects by underpayment and low enough that it does not create an irresistible inducement. This proposal does not underestimate the risks of research, which are often overestimated and need to be appraised in light of the relevant empirical literature. (shrink)

The concept of consensus is often appealed to in discussions of biomedical ethics and applied ethics, and it plays an important role in many influential ethical theories. Consensus is an especially influential notion among theorists who reject ethical realism and who frame ethics as a practice of discourse rather than a body of objective knowledge. It is also a practically important notion when moral decision making is subject to bureaucratic organization and oversight, as is increasingly becoming the case in medicine. (...) Two models of consensus are examined and criticized: pluralistic consensus and overlapping consensus. As an alternative to these models, the paper argues that consensus refers to the dialogic aspects of a broader normative conception of democratic moral agency. When the preconditions for that dialogic democratic practice are met, consensus has a justificatory role in ethics; when they are not, consensus, as distinct from mere agreement, does not emerge and can have no moral authority. Keywords: applied ethics, bioethics, consensus, contract theory, democracy, discourse ethics, liberalism CiteULike Connotea Del.icio.us What's this? (shrink)

History's judgment on the success of bioethics will not depend solely on the conceptual creativity and innovation in the field at the level of ethical and political theory, but this intellectual work is not insignificant. One important new development is what I shall refer to as the relational turn in bioethics. This development represents a renewed emphasis on the ideographic approach, which interprets the meaning of right and wrong in human actions as they are inscribed in social and cultural practices (...) and in structures of lived meaning and interdependence; in an ideographic approach, the task of bioethics is to bring practice into theory, not the other way around. The relational turn in bioethics may profoundly affect the critical questions that the field asks and the ethical guidance it offers society, politics, and policy. The relational turn provides a way of correcting the excessive atomism of many individualistic perspectives that have been, and continue to be, influential in bioethics. Nonetheless, I would argue that most of the work reflecting the relational turn remains distinctively liberal in its respect for the ethical significance of the human individual. It moves away from individualism, but not from the value of individuality.In this review essay, I shall focus on how the relational turn has manifested itself in work on core concepts in bioethics, especially liberty and autonomy. Following a general review, I conclude with a brief consideration of two important recent books in this area: Jennifer Nedelsky's Law's Relations and Rachel Haliburton's Autonomy and the Situated Self. (shrink)

In the spirit of summer, and especially summer reading, we asked a few well-read writers for an essay on a book or books exploring bioethics issues through story. The result is a compelling look at how we face our fears and hopes about biotechnology and medicine. A reading list appears at the end. Bioethics lives in the shadow of great structures and practices of power, and yet, it has not been notable for its contributions to an understanding of power.1 Indeed, (...) the narrative that bioethics has fashioned for itself has been mainly a liberationist romance: a quest narrative in which the individual, seeking autonomy, struggles against limitations, constraints, and inhibitions imposed by forces (rules .. (shrink)

This essay examines the goals of care and the exercise of guardianship authority in the long-term care of persons with Alzheimer's disease and other forms of chronic, progressive dementia. It counters philosophical views that deny both agency and personhood to individuals with Alzheimer's on definitional or analytic conceptual grounds. It develops a specific conception of the quality of life and offers a critique of hedonic conceptions of quality of life and models of guardianship that are based on a hedonic legal (...) standard of “best interests.” As an alternative, it proposes a conception of quality of life based on the notions of “semantic agency” and “memorial personhood.”. (shrink)

This paper argues that more attention should be paid to the civic functions of ethical discourse about the professions and to the moral virtues inherent in their practice and traditions. The ability of professional ethics to articulate civic ideals and virtues is discussed in relation to three issues. First, should professional ethics aim to enlighten ethical understanding or to motivate ethical conduct? Second, how should professional ethics define the professional's moral responsibilities in the face of ethical dilemmas — should the (...) professional attempt to resolve the dilemma ethically or to change the social conditions that create the dilemma in the first place? The third issue discussed in the paper is whether professional ethics should be based on the model of regulation and rational self-interest or on the model of virtue and a fundamental personal commitment to the ideal of a certain form of life? In order for work in professional ethics to attain intellectual credibility among a non-philosophical audience, it must develop a coherent and convincing position on each of these issues. (shrink)

Over the past several decades, a group of scholars at the Berkeley campus of the University of California have frequently challenged many of the dominant themes of contemporary agricultural research. In their work, they have organized curricula questioning the assumptions of conventional agriculture and its sciences while encouraging the development of alternative agricultural practices based on principles of ecology. Their collective critique has stimulated an intellectual climate calling forth a scrutiny of the university's role in the production of knowledge and (...) the social consequences of its works. The result of this intellectual project has been a group that has also largely challenged the dominant themes of the modern university. In place of a setting where ideas are a passive currency, the modern university is a place where knowledge and power are manifest in a dialectic that is revealed not simply by the production of knowledge, but its destruction as well. It is in this context that the recent history of a group of scholars at the University of California provides a striking testimony concerning the disturbing character of science in the modern university. The ecological and social dimensions of “killing fields” that captures the contemporary hazards of food and fiber production in California is also reflected in the gradual demise of a group of researchers at Berkeley who have endeavored to provide an alternative vision of agriculture. (shrink)

The further development of public health ethics will be assisted by a more direct engagement with political theory. In this way, the moral vocabulary of the liberal tradition should be supplemented—but not supplanted—by different conceptual and normative resources available from other traditions of political and social thought. This article discusses four lines of further development that the normative conceptual discourse of public health ethics might take. The relational turn. The implications for public health ethics of the new ‘ecological’ or ‘relational’ (...) interpretation that is emerging for concepts such as agency, self-identity, autonomy, liberty and justice. Governing the health commons. The framework of collective action problems is giving way to notions of democratic governance and management of common resources. The concept of membership. Membership is specified by the notions of equal respect and parity of voice and agency. The concept of mutuality. Mutuality is specified by the notions of interdependent concern and care. (shrink)

To the Editor: The sensitive discussion by Courtney Campbell and Jessica Cox on hospice care and physician-assisted death (“Hospice and Physician-Assisted Death: Collaboration, Compliance, and Complicity,” September-October 2010) is a model blend of ethical analysis, empirical study, and policy assessment in bioethics. The legalization of physician aid in dying has raised important ethical issues for hospice that go to the broader question of its evolving mission and its place in the landscape of end-of-life care in our society. Hospice began, one (...) might say, as a philosophy of care of the dying that formed a countercultural movement. It offered a systematic and holistic approach to care involving not .. (shrink)